So You Have Chronic Abdominal Pain?
Author: Terry Benson, MD
All of us at one time or another has had a problem or pain that cannot be explained or will not go away on its own. These types of problems frequently cause enough interference with daily life to be a concern. The vast majority of the time these problems are benign and not pathologic. The medical term for these conditions is a "functional process or disease."
When a person presents to a physician with a problem or a concern, one of the first things performed is to construct a differential diagnosis (DDx). This is similar to a detective putting a case together. One needs to decide where to look for clues, and how to put the clues together to come up with the best answers.
Functional disease is a disease of exclusion. It is difficult to diagnose and explain, because it is not leading to damaged or destroyed cells/ tissue. The various lab tests, x-rays, and even tissue biopsies will often be completely normal. The diagnosis is made after a careful patient history; often normal physical exam and enough testing to rule out a pathological or psychiatric process. Many times, if not discussed thoroughly, a patient is told all their tests and exam are normal and this is good news. But if functional disease is not explained and addressed by the physician/patient team, the patient walks away frustrated, angry or feeling like they are perceived as being crazy.
It is very important the physician/patient team communicate with each other every step of the way from the beginning - discussing what each test does, which tests are necessary and what the results mean to reach a satisfactory decision. A decision where both parties are confident in the diagnosis.
Irritable Bowel Syndrome (IBS) is a gastrointestinal syndrome that best represents functional disease. It is characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. It is by far the most commonly diagnosed GI condition. Even though only about 15% of people with IBS will seek medical help, it is estimated that in the United States the direct and indirect costs for diagnosis and care of IBS exceeds 30 billion dollars.
The diagnosis of IBS is made by recognizing a broad range of GI symptoms that meet several defined criteria and by excluding other causes. The differential diagnosis of IBS includes inflammatory bowel disease, gluten deficiency, infectious colitis, gastrointestinal cancer, and even ovarian cancer. A person may need to have blood work, stool cultures, colonoscopy, esophagogastroduodenoscopy (EGD), and even CT scan of the abdomen to exclude these other diseases.
There are many different types of functional diseases: musculoskeletal headaches, noncardiac chest pain, fibromyalgia, globus sensation (a sensation of a lump in the throat), chronic pain and many others that are not well defined. Once the physician/patient team is confident in the diagnosis, they can focus on treatment. The hallmark of treatment is first reassurance. These types of problems are not organ or life threatening. People who suffer with functional disease are not psychotic or "crazy." If they were, 80-90% of the world's population would be labeled crazy. Many times once a person knows they have been listened to, taken seriously and reassured that their problem is not pathological, they feel much better. In addition, like all disease it helps to have a healthy diet, regular exercise, adequate sleep and a reduction in stress. Often medications will help to manage symptoms to improve digestion, sleep and pain.
Finally, it is important to maintain ongoing communication with your doctor as functional problems are not cured and need to be managed lifelong. Overall, the prognosis is excellent and your chronic abdominal pain can be diagnosed and managed successfully with your physician.
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